The Deficit Reduction Act of 2008 (DRA) created the Medicaid Integrity Program (MIP) and directed the Centers for Medicare & Medicaid Services (CMS) to enter into contracts to review Medicaid providers actions, audit claims, identify overpayments, educate providers and others on the Medicaid program integrity issues, as well as detect and prevent fraud, waste, and abuse.
Who are the "Audit MICs"?
Audit Medicaid Integrity Contractors (Audit MICs) have now been replaced with the Northeast Unified Program Integrity Contract (NE UPIC). The NE UPIC are entities with which CMS has contracted to perform audits of Medicaid providers. The overall goal of the provider audit is to identify overpayments and to ultimately decrease the payment of inappropriate Medicaid claims. At the direction of CMS, the NE UPIC (formerly the MIC) will Audit Medicaid providers throughout the country. The audits will ensure that Medicaid payments are for covered services that were actually provided and properly billed and documented. NE UPIC will perform field audits and desk audits. Audits have begun in CMS Northeast Jurisdiction and will be expanded to all States in this Jurisdiction. The audits are being conducted under Generally Accepted Government Auditing Standards.
What jurisdiction is Pennsylvania?
CMS has divided the U.S. into five Jurisdictions. Pennsylvania is part of the Northeast Jurisdiction. The NE UPIC Jurisdiction consists of Connecticut, Delaware, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, Pennsylvania, Rhode Island, and Washington D.C. In November 2016 Safe Guard System (SGS) was awarded the contract to serve as the NE UPIC (formerly the MIC) for the Northeast Jurisdiction.
Which providers will be subject to audits?
Any Medicaid provider may be audited, including, but not limited to, fee for service, institutional, and non-institutional, as well as managed care entities.
How are providers selected?
Providers usually will be selected for audit based on data analysis by other CMS Contractors. They also will be referred by State agencies. CMS will ensure that its audits neither duplicate audits of the same provider nor interfere with potential law enforcement investigations.
What should a provider do if it receives a Notification Letter that it has been selected for audit?
Gather the requested documents as instructed in the letter. CMS contractors have the authority to request and review copies of provider records, interview providers and office personnel, and have access to provider billing facilities. Requested records must be made available to the NE UPIC (formerly the MIC) within the requested timeframes.
Generally, providers will have at least two weeks before the start of an audit to make their initial production of documents to the NE UPIC (formerly the MIC). In obtaining documents the NE UPIC will be mindful of Pennsylvania state-imposed requirements concerning record production. Moreover, the NE UPIC may accommodate reasonable requests for extensions on document production so long as neither the integrity nor the timeliness of the audit is compromised. The NE UPIC will also contact the provider to schedule an entrance conference. Notification Letters will identify a primary point of contact at the NE UPIC if there are specific questions about the Notification Letter or the audit process.
What process will follow the completion of the audit?
The NE UPIC (formerly the MIC) will prepare a draft audit report, that includes all findings and recommendations related to the audit that will be reviewed and approved by CMS. The provider will be notified of the audit results and has state required time limits to provide written feedback and documentation to the audit team. If the provider does not submit additional information or comments, the audit team will prepare a Final Audit Report. If the provider submits additional information or comments and the audit team determines no revision is warranted, the Final Audit Report will be issued. If the audit team concludes the additional information changes the outcome of any claim line determinations a Revised Draft Audit Report (RDAR) will be sent to the CMS for review and approval. Once approved by CMS, NE UPIC (formerly the MIC) and BPI will issue the Final Audit Report. An exit meeting will occur with the provider to clarify the final audit report and explain the overpayment amount and how it was determined. Pennsylvania will pursue the collection of any overpayment in accordance with the State Law. Providers have full appeal rights under Pennsylvania State law. The NE UPIC will be available to provide support and assistance to Pennsylvania throughout the state’s adjudication of the audit. An exit meeting will occur with the provider to clarify the final audit report and explain the overpayment amount and how it was determined.
For information on the Medicaid Integrity Program, please email Medicaid_Integrity_Program@cms.hhs.gov.